Pursuing the Triple Aim in Hotspotters: Identification and Integrated Care

People with complex problems on multiple life domains receive fragmented care. The accumulation and complexity of problems is difficult to manage for patients and care providers, and leads to high medical spending with little effect of care. In this study the investigators will evaluate the costeffectiveness and experience of care of integrated, proactive and personalized care for patients with problems on 2 out of 3 life domains and at least 2 acute care contacts in the previous year. A stepped wedge randomised controlled trial will be performed in 20 general practices that do not yet offer such an approach.

People with complex problems on multiple life domains, so called 'hotspotters', receive fragmented care. This is difficult to manage by patients and care providers , leading to little effect of care and persistent unmet needs. The accumulation and complexity of problems often leads to high medical expenses. Next to their high medical spending levels, hotspotters´ experiences with the healthcare system are low as the healthcare system is not (yet) successful in dealing with their needs. Interventions aimed at the complex situation of hotspotters in our current healthcare system might benefit by applying a Triple Aim approach. This approach aims to simultaneously improve the individual experience of care, reduce the cost of care per capita and improve the health of populations by offering proactive integrated care. Is proactive integrated care costeffective and does it result in better patients experience than usual care after 12 months for patients with problems on multiple life domains? A stepped-wedge cluster randomised controlled trial (RCT) design will be used This study will be performed in 20 general practices that do not yet offer proactive integrated care for hotspotters. Data on cost-effectiveness will be quantitatively assessed. Patient experience will be qualitatively assessed through focus groups and quantitative using validated questionnaires. Besides, the process will be both qualitatively and quantitatively evaluated using interviews or focusgroups, observations (audio recording) with care professionals on common themes of process evaluatation and a validated questionnaire. In total 200 hotspotters will be included. Hotspotters are individuals with at least two incidents of acute care utilisation (defined as out-of-office GP consultations, acute psychiatric care, emergency department visits and unplanned admissions) during the past year, and problems on two out of three health domains (chronic somatic, mental and/or social problems) based on diagnosis (coded with the International Classification of Primary Care) or medication (ATC) coding. The proactive integrated care intervention that will be used consists of five steps: Active invitation of the patient from the practice. Consult of 45 minutes with a trained Practice Nurse Mental Health Care based on the Positive Health Methodology. Multidisciplinary team meeting based on the spider web with domain specific explanation to create a personalised care plan and assign a care coordinator to each patient. Execution of the personalised care plan and frequent pro-active contact between care coordinator and the patient. In the first 12 weeks there is a minimum of 3 contact moments, however more frequent contact is expected. The proactive nature of this contact is emphasized. Follow-up of the personalised care plan using clinical review and at least one multidisciplinary meeting. If needed, ad hoc additional meetings can be organised.

high care utilizer, complex patient, problems on multiple life domains, frequent flyer, hotspotter, high needs patient, integrated care, proactive care, personalised care, personalised care plan, positive health tool, multimorbidity, psychosocial problem

During the intervention patients receive proactive, integrated and personalised care. An intake consultation using Positive Health tool, or a similar method, the needs of each patient is assessed. In a multidisciplinary meeting with the GP, mental health care practice nurse, a social worker and the patient, a personalised care plan is made. The personal is executed and a care coordinator maintains proactive contact with the patient. Clinical follow-up will be done via a second multidisciplinary meeting.

Costs of care from a societal perspective is the summ of costs of care and loss of productivity due to illness or disease. Data on frequency and type of care utilization is gathered from the GP medical file, supplied with questions on mental health care use and need for addiction care. Productivity loss is determined via questionnaire. This data will be translated into cost using standard cost prices from the Dutch guideline for economic evaluations. Cost of care, together with Quality of life, will be used to assess cost-effectiveness from a societal perspective.

QALY measured by recurring EQ-5D-5L. Quality of life, together with cost of care, will be used to assess cost-effectiveness from a societal perspective.

Researchers evaluate patients experiences with the personalised, integrated and proactive care approach using two methods. First, using questionnaires. An adapted Net Promotor Scale and the Health Care Climate Questionnaire (HCCQ) will be administered 6 months after the new care approach starts. Second, a focusgroup is organised to gather insight into the experiences of patients.

Self-efficacy will be measured using two different instruments. The first is the validated Patient activation Measure (PAM-13). This is a 13-item instrument that measures self-reported knowledge, skills and confidence in managing one's health. The second questionnaire is the Self-efficacy and Intention itemlist (SE+IN Itemlist). This itemlist, specifically created for this study, measures (action and maintenance) self-management self-efficacy, the intention to perform certain self-management behaviors and the presence of certain self-management behaviors.

The presence of proactive coping skills will be quantitively measured with the Utrechtse Proactieve Coping Competentie lijst (UPCC). This is a 21-item questionnaire that measures self-rated proactive coping competences. This questionnaire is administered thrice: at the start and end of intervention, and two months after ending the intervention.

Quality of life will also be assessed using the validated SF-12(12-items), including 8 dimensions, namely: bodily, pain, vitality (energy and fatigue), general mental health (psychological distress and well-being), general health perceptions, limitations in physical activities because of health problems, limitations in social activities because of physical or emotional problems, limitations in usual role activities because of emotional problems, and limitations in usual role activities because of physical health problems. This questionnaire is administered thrice: at the start and end of intervention, and two months after ending the intervention.

Level of shared decision making will be based on audio recored which will be scored by two independed observers using the validated OPTION5 questionnaire. If a participant is not comfortable with these recordings, the recorings may be skipped without further consequence for study participation.

Professionals fill in the integrationmeter at the start and end of the intervention, resulting in a degree of care integratrion.

Acceptability, appropriateness, and feasibility will be measured using the The Acceptability of Intervention Measure (AIM). This will be done before the intervention starts and right after the intervention for each group of GP's. This information will be gathered from care professionals from participating as well as non-participating practices.

Intervention Appropriateness Measure (IAM), together with Feasibility of Intervention Measure (FIM), measures implementation outcomes that are often considered "leading indicators" of implementation success. This will be done before the intervention starts and right after the intervention for each group of GP's. This information will be gathered from care professionals from participating as well as non-participating practices.

Feasibility of Intervention Measure (FIM), together with Intervention Appropriateness Measure (IAM), measures implementation outcomes that are often considered "leading indicators" of implementation success. This information will be gathered from care professionals from participating as well as non-participating practices.

Inclusion Criteria: The patients are ≥ 18yrs The patients are registered within one of the participating GP practices. Patients with at least two acute care encounters in the past 12 months. Acute care encounter is defined as an encounter with out-of-hours GP service, emergency care or acute mental health care.Patients have problems registered in the GP Information system on at least two out of three of the following domains: somatic, mental or social. Somatic problems is having at least one ICPC code on the problem list. Mental problems is having at least one ICPC code from the "P"-chapter on either the problem list, as a reason for encounter, and/or having medication prescribed related to mental health problems. Social problems is having at least one ICPC code from the "Z"-chapter or as reason for encounter, and/or having medication prescribed related to social problems. Exclusion Criteria: The patient is terminal. The patient is living in a residential home. The patient has dementia or a disability that prevents them from communicating effectively.The patient already has experience with the positive health tool. The patient is not competent to make decisions concerning their health. This wil be assessed by the patient's own general practitioner. Veto of the GP

Leiden University Medical centre, department of Public Healht and Primary care (PHEG), location Health Campus The Hague